Page 37 - JSOM Spring 2024

FIGURE 1 Mean expert participant scores of each checklist item for FIGURE 2 Proportion of expert responses to include a given item on
rounds 1 and 2. the final checklist.

The x-axis represents the mean score for each round with error bars
representing standard deviations. The y-axis represents the proportion
of responses to include a given item. The horizontal line represents a
The x-axis represents the mean score for each round with error bars proportion of 0.7 (70%) to include a given item.
representing standard deviations. The y-axis represents the individual
checklist item. The horizontal lines represent a mean score of 3 and a
mean score of 7.

TABLE 3 Final Procedural Performance Checklist for Bifemoral Veno-Venous Extracorporeal Membrane Oxygenation (ECMO)
1. Consider utilizing two sterile personnel for this procedure.
2. Assess the patient for any contraindications prior to procedure.
3. Prime and prepare ECMO circuit. Flush cannulas with sterile saline and tighten all stopcocks and caps on the cannulas.
4. Assess femoral vein anatomy bilaterally and evaluate using ultrasound prior to starting procedure.
5. Put on sterile gloves. Use sterile probe cover for ultrasound as available.
6. Clean insertion sites.
7. Using ultrasound, identify the needle insertion site that will allow cannulation of the femoral vein cephalad to the insertion of the saphe-
nous vein but below the inguinal ligament bilaterally.
8. Insert introducer needle with or without syringe under ultrasound guidance to the 12 o’clock position of the right femoral vein. Micro-
puncture use can be considered.
9. Visualize insertion of the needle into the right femoral vein and confirm with return of blood into the syringe, if used.
10. Remove syringe, if used. Place 180cm 0.035 J-tip wire through introducer needle or micropuncture sheath.
11. Confirm placement of wire within the right femoral vein and directed toward the right atrium using ultrasound guidance. Remove needle,
leaving wire in place OR. if micropuncture was used, remove sheath, leaving wire in place. If the patient is attached to continuous telemetry
monitoring, ectopy may also be observed, indicating wire in the right ventricle. Retract the wire until ectopy is no longer observed.
12. Insert introducer needle with or without syringe under ultrasound guidance to the 12 o’clock position of the left femoral vein. Micropunc-
ture use can be considered.
13. Visualize insertion of the needle into the left femoral vein and confirm with return of blood into the syringe, if used.
14. Remove syringe, if used. Place 180cm 0.035 J-tip wire through introducer needle or micropuncture sheath.
15. Confirm placement of wire within the left femoral vein using ultrasound guidance. Remove needle, leaving wire in place OR. if micropunc-
ture was used, remove sheath, leaving wire in place.
16. Once both wires are in place in each femoral vein, administer an IV bolus of heparin. Heparin bolus may be withheld if anticoagulation is
contraindicated as determined by the proceduralists (high risk of bleeding complications, active and ongoing correction of coagulopathy, etc).
17. Perform skin incision at wire. Sequentially dilate the return cannula site over wire. 1/3 to 1/2 of dilator should be placed with each dilation.
Ensure wire can easily move back and forth during each dilation. Dilate to one size smaller than planned cannula size.
18. Advance return cannula with introducer until position in right atrium is confirmed with ultrasound guidance.
19. Remove wire and introducer from return cannula, back bleed the cannula, and clamp the end.
20. Flush return cannula with sterile saline (may be heparinized if desired) and clamp the end.
21. Perform skin incision at wire. Sequentially dilate the drainage cannula site over wire. 1/3 to 1/2 of dilator should be placed with each dila-
tion. Esnure wire can easily move back and forth after each dilation. Dilate to one size smaller than planned cannula size.
22. Advance drainage cannula with introducer until the last hole is through skin and not visible. Retract introducer to designated line. Advance
drainage cannula.
23. Remove wire and introducer from drainage cannula, back bleed the cannula, and clamp the end.
24. Flush drainage cannula with sterile saline (may be heparinized if desired) and clamp the end.
25. Place circuit tubing on the field identifying drainage and return tubing and placing next to drainage and return cannulas.
26. Connect drainage cannula to circuit with air-free technique.
27. Connect return cannula to circuit with air-free technique.
28. Esnure no air entrainment in the circuit.
29. Initiate circuit flow, remove clamps closest to cannulas and then remove clamps closest to circuit.
30. Note cannula positions.
31. Secure cannulas with purse string non-absorbable suture where cannula enters the skin and at least additional securing sutures on the legs.
32. Cover cannula sites with sterile dressings.

Checklist for Bifemoral VV ECMO Cannula Placement in Operational Environments | 35